Mental State Examination Flashcards
What is a mental state examination and what does it include?
Begins from the moment you see them, or even their property.
Refers to the time you see them: anything previous (e.g. hallucinations yesterday) goes in the history.
Components are ASEPTIC: Appearance, Speech, Emotion (mood), Peception, Thought, Insight, Cognition.
What the key features to consider in the appearance and behaviour domain?
Key points:
Note self-care, rapport, and any abnormal behaviours. Comment on any physical problems, including if they’re overweight.
Example comment: “They were casually dressed, well-kempt, calm, and had good eye contact. Rapport was easily established”.
Abnormal behaviour:
Too much: disinhibition and over-familiarity.
Too little: withdrawn, poor eye contact, and poor rapport.
Signs of distress: hand-wringing, agitation, tearfulness.
Abnormal movements:
Motor slowing: depression, schizophrenia.
Dyskinesia e.g. choreoathetosis from drugs, schizophrenia, or neurological disease.
Tremor: drug-induced or neurological.
Stereotypies: schizophrenia.
Catatonia: either waxy flexibility or stupor and akinetic mutism. Seen in schizophrenia, depression, or neurological disease.
What are the key features to consider in the speech domain?
Key points:
Comment on quantity, rate, volume, tone, and articulation (smooth, dysarthria, or stammer).
Example comment: “Speech is of a normal quantity, rate, volume, and tone, and is fluent and smooth”.
Abnormalities:
Slowing, part of psychomotor slowing.
Mutism: may be elective or involuntary.
Fast speech: schizophrenia, mania.
Pressured: fast and uninterruptable, often seen in mania.
Neologisms: seen in schizophrenia and neurological diseases.
Incoherence, which may be due to disordered thought. Note that abnormal speech content may be hard to distinguish from disordered thought.
Echolalia: repeating words, seen in schizophrenia and dementia.
What are the key features to consider in the mood domain?
Mood is their underlying feeling, while affect is their moment-to-moment emotion.
Mood: may be euthymic, dysphoric/low, euphoric/elevated, angry, anxious, apathetic, or irritable. Comment on subjective and objective mood.
Affect: note their reactivity, which may be reactive (normal), blunted or labile. Also note if it is incongruent with their thought content e.g. they seem happy while describing traumatic events.
Example comment: “the patient was subjectively and objectively euthymic, with reactive affect”.
What are the key features to be considered in the thoughts domain?
Preoccupations or worries e.g. hypochondriasis.
Obsessions: recurrent, distressing, and ego-dystonic thoughts e.g. in OCD.
Overvalued ideas: mild delusions which they sort of know are untrue but can’t shake.
Delusions: false beliefs, unchanged by evidence, which are culturally incongruent.
Delusional perceptions: delusion arising from false interpretation of real perception e.g. shopkeeper giving you change is a spy delivering a message. Comes on out of the blue.
Thoughts of suicide, self-harm, or harm to others.
Example question: “Has there ever been times when you’ve thought something strange is going on?”
Persecutory delusions:
“Is there anything worrying you at the moment, particularly regarding other people?”
“Do you feel other people are up to no good?”
“Do you feel people are following/spying on you?”
Ask about details and response including home security, weapon carrying. Worry if specific ‘persecutor’ is identified as they may be at risk.
Delusion of reference:
Thinking that trivial events have special personal meaning e.g. the advert on TV is about them.
“Have you seen anything lately which has stood out as being particularly important to you?”
“Has anything been reported on news or TV which has been particularly important?”
Ideas of reference are a milder feeling, which are accepted as false on challenge.
Grandiose delusions:
“Do you feel you have any special talents that other people don’t?”
“Do you feel you have a special relationship with God?”
“Are you famous for anything?”
“Do you have a mission in life?”
Thought interference or alienation:
Broadcasting, insertion, or removal of thoughts.
Insertion: “is anyone putting thoughts into your head?”
Removal/withdrawal: may feel a ‘gap’ in thoughts and feel it was stolen.
Others delusions:
Delusions of passivity/control: believe that own thoughts/feelings/actions are controlled by others. Nihilistic delusions. Hypochondrial delusions. Delusions of worthlessness. Delusions of guilt. Thought form Mania:
Flight of ideas.
Schizophrenia:
Circumstantiality: doesn’t get to the point. Also seen in mania and OCD.
Tangentiality: going off topic.
Poverty/paucity of thought. Also seen in depression and dementia.
Perseveration: repeating word/phrase/gesture when the appropriate stimulus has stopped e.g. keeps answering different questions with the same answer. More commonly seen in organic disease, but sometimes in schizophrenia too.
Loosening of associations, including (a) derailment (aka knight’s move thinking), where they jump between thoughts, (b) thought blocking, where they stop mid thought, and (c) word salad, an unintelligible mix of words.
If normal: “No formal thought disorder”.
What are the key features to consider in the perceptions domain?
Hallucinations:
Sensation without stimulus. Commonly auditory in psychiatric disease, and visual in neurological disease.
Auditory hallucinations can be 2nd or 3rd person, the latter almost only in schizophrenia.
Questions: “Do you see or hear things other people don’t?”, “Do you hear people talking to you when you can’t see them?”
Other abnormal perceptions:
Illusion: misperception of real stimulus.
Pseudohallucinations: know it’s ‘inside the head’ and it lacks the quality of a real perception. Usually auditory. Can include 2nd person, command hallucinations in personality disorders.
Depersonalisation – an out of body feeling – and derealisation – the world around feels unreal. Can be caused by fatigue or panic attacks.
What are the key features to consider in the cognitive testing domain?
General function can be tested with a simple evaluation of orientation in person, place, and time i.e. their name, where they are, and the day, date, and time of day.
Mini Mental State Exam (MMSE) is a brief test of cognitive function. Results: ≤26 mild impairment, ≤20 moderate impairment, ≤10 severe impairment. The Montreal Cognitive Assessment (MoCA) is an alternative, with thresholds at 26, 18, and 10.
Addenbrooke’s Cognitive Examination Revised (ACE-R) is a more detailed test: <85 suggests an impairment.
Test of attention and concentration: months of the year backwards
Test of memory: retain and recall 3 objects or a 5 part name and address. Assesses both immediate and delayed recall.
If not tested but seems normal, say: “Cognitive function not formally examined, but no obvious abnormality.”
What are the key features to consider in the insight domain?
3 parts: knows the experiences are (1) abnormal, (2) due to disease, and (3) can be medicated.
Usually not straightforward yes or no, but somewhere in between.
Strictly speaking, insight is not compatible with having delusions or hallucinations. However, some people reach a point where they know on some level that the delusions and hallucinations are part of the illness, but still experience them as real.
Questions:
“Why do you think this is happening to you?”
“This must be awful. Is it making you feel unwell? Would you be willing to try some medication?”
“Do you ever feel like your mind plays tricks on you?”
